Trauma-informed practice: our policy perspective

This short policy summary is part of a series setting out the major changes that are needed to improve mental health. It draws upon Mental Health Foundation research and analysis which can be found in the 'further reading' section.   Contents:

• What is trauma?
• Why is trauma a policy issue?
• Adverse Childhood Experiences explained
• What is trauma-informed practice? 
• Our vision for trauma-informed practice
• Policy recommendations for trauma-informed care
• Further reading

What is trauma?

Individual trauma results from an event, series of events, or set or circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being.

U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration^[1]  

It has been estimated that more than 70 per cent of the general population has been exposed, either directly or indirectly, to a traumatic event, where a traumatic event is defined as actual or threatened death, serious injury or sexual violence.^{[2] [3]} Trauma takes place when people are in real or perceived danger. Such experiences alter the way an individual perceives their environment and relationships, leading them to expect danger, especially from situations that are similar to the context of the original trauma. 

Physiologically and psychologically, individuals who have experienced trauma are primed for threat detection. They frequently show heightened sensitivity to danger (hypervigilance) and rapid reactivity (the fight-flight-freeze response). 

The situation that activates the stress response (the trigger) and the effects of this activation (the response) vary from individual to individual. Triggers are shaped by the context in which trauma has taken place. The individual learns to associate aspects of the context of the original trauma with danger and responds accordingly. This stress response takes a toll on mental and physical health, and day-to-day functioning.

Why is trauma a policy issue?

Trauma is a major risk factor for poor mental health. It can be a direct cause of Post-Traumatic Stress Disorder, and can play a part in the development of anxiety and depression.^{[4] [5]}

Trauma experienced in childhood in the form of ‘adverse childhood experiences’ (ACEs) leads to a substantially higher risk of poor wellbeing, mental ill health, and other negative outcomes during the whole lifetime of the person affected.^[6]  For example, analysis shows that 46% of individuals with depression^[7] and 57% of people diagnosed with bipolar disorder report high levels of childhood maltreatment.^[8] A landmark study found that experiencing a high number of ACEs (four to six compared to zero) increases the chance of depression by 460%, suicide attempts by 1,220% and intravenous drug misuse by 4,600%.^[9]

Trauma survivors are vulnerable to retraumatisation (reactivation of old traumas) and revictimisation (experiencing new traumas). As a result, trauma survivors are a vulnerable population.^[10][11] However, to discuss trauma as a universal experience, although valid, conceals the fact that it is not evenly distributed in society.^[12][13] Trauma disproportionately affects marginalised populations and is inseparably bound up with systems of power and oppression.^[14][15][16]

In recent years, understanding of trauma has grown enormously. There is both a greater awareness of its prevalence in society and deeper knowledge of its long-term effects on survivors. With this has come recognition of the role organisations and institutions often play in perpetuating trauma, inadvertently causing further harm to some of the most vulnerable people they work with. This is referred to as ‘systemic trauma’, a broad concept that includes both abstract structures, such as societies, cultures and families, and more concrete institutions, such as hospitals and schools. 

The concept of systemic trauma is based on an understanding of trauma as an adaptive response to external conditions. It moves the conversation about trauma beyond the walls of the clinic and out into wider society. If systems of any type can give rise to and perpetuate trauma then, by extension, they also have a role – and, some have argued, a responsibility – to play in its prevention and healing.^[17]

Addressing trauma, then, is not only a question of delivering trauma-specific services to individuals with a PTSD diagnosis, but of trauma-informed practice delivered across the public sector and wider society. 

As we consider the longer-term repercussions of the pandemic, there is growing recognition that trauma-informed approaches are now needed more than ever; evidence points to increased rates of post-traumatic stress disorder following pandemics.^[18]

Our report Engaging with Complexity,^[19] which focused specifically on women’s experiences, found that there are barriers to public services becoming trauma-informed. These include resistance both to acknowledging the importance of trauma and to changing long-established practices, as well as scarce resources and low morale. But it finds that adopting the principles of trauma-informed practice can make services more effective in responding to the needs of women who have experienced trauma.

What is trauma-informed practice?

Trauma-informed practice can respond to individuals’ experiences by listening to and valuing people’s stories by creating safe spaces to talk, by showing an understanding of the traumas people have experienced, and by responding to their needs without creating new traumas.

Trauma-informed practice:

• puts people before protocols.
• does not try to make people’s needs fit into pre-specified boxes.
• creates a culture of thoughtfulness and communication, continuously doing their best to learn about, and adapt to, the different and changing needs of the individuals they work with.

In order to do this, it is crucial that services are willing and able to engage with complexity. As a result, trauma-informed practice is most usefully defined in terms of ongoing processes, approaches and values, rather than fixed procedures.

The US-based SAMSHA (Department of Health and Human Services Substance Abuse and Mental Health Services Administration) describes a trauma-informed approach as following ‘4 Rs’:

 "a program, organization or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization".^[20]

Our vision is that an understanding of trauma should underpin all interactions between the public sector and people across the UK. This means recognising the widespread impact of trauma, acknowledging it in people who use public services, and creating safe spaces in which public service staff treat everyone with sensitivity, empathy and cultural humility. The state should never take action likely to cause trauma.

Policy recommendations for trauma-informed care – UK-wide & England

In addition to setting policy and legislation for England, the Westminster Government has power over a number of UK-wide issues, including education and asylum policy. 

1. The government should institute a trauma-informed workforce programme for England similar to that which is being delivered in Scotland.^[21]
2. The government’s upcoming Major Conditions Strategy for England must put the four processes of listening, understanding, responding, and checking at the heart of how public services interact with service users, especially where they regularly interact with vulnerable people. Given the current cost-of-living crisis, it is particularly important that this includes DWP, debt and money advice services, and NGOs working with people experiencing poverty such as foodbank services. 
3. In England, the Department for Education should work with schools, local authorities, education and mental health charities to develop guidance for teachers and schools to increase their understanding of trauma-informed approaches and enable them to support children and young people. 
4. Across the UK, the Home Office and its agencies should become trauma informed organisations, able to operate with understanding of the trauma that is experienced by many asylum seekers. High quality trauma-informed training should be provided to all relevant staff and representatives to ensure people are treated with understanding, compassion and dignity as they go through the system. Additionally, the UK Government should commit to rolling out trauma-informed training, specific to the experiences of asylum-seekers and refugees, across public sector staff (e.g.: healthcare, education, transport and the police), to avoid the risk of re-traumatisation when engaging with public services.
5. The Home Office should carry out work, in partnership with people with lived experience of seeking asylum, to re-design the asylum system to ensure it does not re-traumatise individuals. This should include ensuring that asylum-seekers never need to re-explain their stories as they go through the system, as this can have a poor impact on their mental health.

Published: November 2023. For review: May 2024